Establishing spirituality as an intermediary determinant of health among 42,843 children from eight countries

The World Health Organization (WHO) Commission on the Social Determinants of Health (CSDH) conceptual framework identifies socio-economic position as a structural determinant of health. Recognized intermediary determinants include biological, behavioural, and psychosocial factors. We examined whether connections afforded by a healthy spirituality potentially act as unrecognized intermediary determinants in adolescent populations, contributing to inequities in mental health. Reports from 42,843 children (21,007 boys, 21,836 girls) from eight countries who participated in the 2017–2018 Health Behaviour in School-aged Children (HBSC) study were used to describe correlations between family affluence and positive levels of mental health, using a cross-sectional design. Based on the CSDH conceptual framework and multivariable regression analyses, we then examined whether these associations were mediated by spiritual health. Connections afforded by a high level of spiritual health were universally correlated with positive mental health status. In three Western European nations (England, Scotland, and Wales) and Canada affluence was correlated with better mental health and this was partially mediated by spiritual health. Among the four Eastern European countries (Latvia, Lithuania, Moldova, Poland), our findings did not support aspects of the CSDH framework that focus on affluence as a direct determinant of health. Spiritual health potentially is an intermediary determinant of children's health in some Western countries, but not in Eastern countries. The universality of social determinants of health models and the measures used in their evaluation require careful assessment across cultures, political contexts, and health outcomes

Structural validity of a brief scale adapted to measure adolescent spiritual health.

Spiritual health is established as an important protective health asset in child populations. Measurement and assessment of this elusive concept are, however, challenging. Brief and age-appropriate instruments are required for surveys and related population health research. One longstanding model describing child spirituality suggests that scales and measures consider four standard domains describing connections to self, others, nature, and the transcendent. In this validation study, we tested the structural validity and internal consistency of a brief, literacy-level appropriate instrument for adolescents that was based on prior adaptations of this model. The 2018 cross-national study population included 47,180 children aged 11-15 years from 9 countries. Based upon theory, factor pattern matrices, and Scree plots, the exploratory factor analysis best supported the four-factor model, with items organized according to the original four domains. Internal consistency of the items was acceptable (alpha>.7) to good (alpha>.8) within domains, again within each of the 9 countries. The confirmatory factor analysis again supported the four-factor model (by country, SRMR: 0.020 to 0.042; and AGFI and NFI fit: >0.98). Model fit indices for the four-factor model were improved compared with its unidimensional version. Moving forward, our analysis establishes the structural validity and internal consistency of this adapted brief spiritual health instrument to be used in surveys of adolescents